Americans have struggled through multiple presidential terms with concerns that would be unfamiliar elsewhere in the wealthy, industrialized world: Is health care a right or a privilege? Must medical services come with crushing costs? And should individuals and their families bear the burden of bankrupting medical expenses on their own, or should some part of society step up to help?
The Covid-19 pandemic has exposed the vulnerabilities of the $3.6-trillion U.S. health care system in ways that its critics, supporters, and participants never could have imagined. This will mean that whoever occupies 1600 Pennsylvania Avenue for the next four years, starting in January 2021, will confront significant challenges in ensuring Americans get the access they need to safe, affordable, and excellent health care.
It may be helpful to undecided voters, as well as all of us who need medical services, to take a tough, global look at the rising signs that our health system is in a big mess and requires urgent attention, especially on dollars-and-cents issues.
Costly U.S. health system shows many symptoms of being globe’s ‘sick man’
It is, sadly, too easy to turn up metrics that show the burgeoning problems in the U.S. health care system.
The most glaring of these arise from the Covid-19 pandemic. Americans account for 4% of the world’s population, but 22% of the global coronavirus deaths (more than 200,000 and rising by the day). Put the U.S. pandemic performance up against that of many other industrialized and wealthy nations and, statistically speaking, tens of thousands of Americans would not have been Covid-19 victims if the U.S. coronavirus response had been comparable to what peers undertook.
With more than 7 million Americans infected with the coronavirus, medical scientists are just starting to see the disease’s longer-term toll: Many of those who contract Covid-19 may go without symptoms or have mild cases from which they will recover fully and swiftly.
But an increasing number of coronavirus patients, the “long haulers,” experience sustained health problems. They not only get saddled with big bills for their urgent hospital care. They also may require expensive medical services for months after — maybe longer.
The pandemic also is wreaking havoc on already negative trends for U.S. health care.
The glum financials
Medical debt, one of the disgraces of the world’s most expensive health care in the wealthiest of nations, has spiked in recent times. A consumer finance firm recently found that its 22 million members carry $45 billion in bills owed to providers. With the coronavirus also staggering the economy, crushing medical debt is only likely to skyrocket as the nation’s 30 million jobless exhaust their finances and lose health insurance from their work.
Health insurance offers one of the few widely available means for ordinary folks to try to protect themselves and their loved ones from seeing their finances destroyed by illness or injury.
But new U.S. Census data, describing a time before the pandemic, shows that “the first three years of President Trump’s tenure were a period of contracting health insurance coverage,” the Washington Post reported. “The decreases reversed gains that began near the end of the Great Recession and accelerated during early years of expanded access to health plans and Medicaid through the Affordable Care Act — the sprawling law that was a signature domestic achievement of President Barack Obama and has been derided by Republicans, including Trump, ever since.”
Just under 30 million Americans were uninsured — 1 in 10 of us, with the numbers rising by several million over the last several years of the Trump term.
Most of us get our health coverage through employer-supported health insurance plans. But due to the pandemic’s economic shocks, which have led to soaring joblessness, an estimated 12 million Americans have lost work-related health coverage.
Many of the millions of jobless will join the risky ranks of the uninsured. Or they will be forced to race through a maze of complex fact-finding and decision-making to see if they are poor enough now to qualify for Medicaid (depending on the state they live in). Or they may get help in securing coverage on ACA marketplaces. Or if they will fork over hefty sums, they may keep their existing policies under a program called COBRA.
Medicaid, by the way, is providing a lifeline to millions of Americans, especially because the ACA vastly the program for the poor and working poor. But as its ranks swell, particularly with the jobless, state officials are expressing big worries about funding for the program, a responsibility shared between states and the federal government.
The employed have struggles, too
Even if they have stayed on the job with their employer coverage, American workers still can face major health care issues. Employers, struggling themselves and confronting ever-rising health insurance costs, have kept shifting them on to employees, notably through spiking out-of-pocket patient expenses that result from rising deductibles.
These soaring expenses and skimpier employer coverage have meant that increasing numbers of the employed were underinsured, struggled with medical bills, and faced lingering financial problems, a recent study found.
The results are likely more severe than reported, as the research focused on a period that ran into early 2020, just when the pandemic struck, throttled the economy, and led to layoffs and other employer cutbacks.
For all Americans, the relentless rise in costs continues to be a basic part of U.S. health care. And little comfort can be found in recent information on two major cost drivers in the system: climbing prescription drug prices and hospital charges.
Relentless cost increases
Contrary to what political partisans may be telling the public, prescription drug costs have not declined and, instead, have kept increasing, the Washington Post reported, noting: “For a short period of time, prices did somewhat drop. Consumer prices for prescription drugs fell 0.6% in 2018, according to the Bureau of Labor Statistics. But the trend reversed last year, when prices increased 3% — the sixth-highest category of growth after smoking products, medical care, energy, shelter, and food away from home.
“This past July, a month in which drug manufacturers traditionally hike prices, 67 drugs increased in cost by an average of 3.1%, according to GoodRx, an online prescription cost service. More than 850 brand-name and generic drugs increased in price by an average of 6.8% in the first six months of the year. In a new analysis … GoodRx found drug prices are surging faster than any other medical service or good, increasing by 33% since 2014.”
The president’s failure to work with his own party members in Congress, or across the aisle, has left him racing as the election nears to pull out hocus-pocus policy steps, notably much-hyped executive orders with little chance of affecting drug prices. This is especially true because Big Pharma will fight, tooth and nail, against cost-control measures, especially if they lack powerful support, and because administration plans fail to account for the interests of significant parties — like consumers in Canada.
Hospitals’ quest for profits
As for hospitals, recent research by the independent, nonpartisan RAND Corporation raises sizable questions about institutions’ rising charges.
Researchers from the think tank found that “hospitals across the country are charging private insurance companies 2.5 times what they get from Medicare for the same care,” the New York Times reported.
Medicare negotiates aggressively on the cost, quality, and safety of services using its size and governmental clout, its advocates say, noting that the system sets tough limits as to what it will pay providers. Those providers long have complained that Medicare reimbursements are too low. At the same time, patients and employers have howled that — lacking Medicare’s capacities — doctors and hospitals take advantage of them, charging far more than what they would accept from Uncle Sam.
As the newspaper reported: “Employers provide health insurance coverage for more than 153 million Americans. The companies and insurers in the study paid nearly $20 billion more than Medicare would have for the same care from 2016 through 2018, according to the RAND researchers. The findings cast doubt on the ability of private employers and insurers to competitively purchase health care for workers and their families compared to the federal government, said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, which helped fund the study. ‘You have this widening gap,’ she said. Proponents of a so-called public option seize on such price-gouging news to argue that creating a government health plan that could use its clout to demand lower prices would help bring down the cost of care.”
It is true that hospitals have gotten banged up by the pandemic, particularly their finances. The Wall Street Journal dug in and reported that the institutions’ own long and aggressive pursuit of profits helps to explain why. Hospitals have been on a spree of mergers and acquisitions. On their sprawling campuses, they have thrown up fancy buildings filled with pricey high-tech equipment, expanding their expensive specialty care. At the same time, they have thrown tentacles into communities with convenient satellite facilities (easy parking!) for urgent and emergency care, or targeted surgical practices. Hospitals boosted executive pay and staff hiring, though more on their business side (as in bill collection) and not so much in direct patient care. They made clear to their communities that if money could be made, they were all in — they boasted about their “comprehensive” services and care.
The pandemic, however, took hospitals back to basics, with lots of desperately ill patients filling beds and requiring intensive attention from a variety of doctors and nurses. Hospitals and doctors have led the way as U.S. medicine has gone through an expensive retrenching, giving front-line health workers (doctors and nurses) premium pay, retraining specialists to handle not only pricey advanced services but also general care, and shutting down treatments deemed in an emergency to be non-essential.
Patients, fearful of infection, also have begun to question how establishment medicine operates. Were all the tests and procedures — to which they assented so readily before and paid for in the ticky-tack, fee-for-service process plaguing U.S. health care — so necessary? Was it really up to patients to bear with hard-to-get appointments, packed waiting rooms, and distant facilities? With unemployment raging and the economy shaky, what medical costs are avoidable for broke patients?
Patients and practitioners alike are feeling their way about normality in health care, with postponed or canceled medical care an increasing worry. Are patients putting themselves at higher risk by delaying exams for cancer or heart disease? Will outbreaks of other infections occur because too few youngsters are keeping with scheduled vaccinations for preventable diseases, much less check-ups for normal development? Has telemedicine taken root, lessening caregivers’ needs for facilities? Uncertainty has become a new normal in so many parts of Americans’ pandemic lives that it is unsurprising how it has become a key part of their health care, even if it may not be beneficial to them.
Americans pay more for poorer outcomes
Other nations don’t share our struggles with health care. We’re an outlier. Americans spend 18% of the nation’s gross domestic product on health care. But we lag in key outcomes in comparison to counterparts in the wealthy, industrialized world, whether they be European (e.g. Britain, France, Germany etc.) or Pacific nations (Australia, Japan, and Korea).
Here are key points from research by the independent, nonpartisan Commonwealth Fund, on how the United States stacks up with nations with advanced economies and membership in the Organization for Economic Cooperation and Development (OECD):
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The U.S. spends more on health care as a share of the economy — nearly twice as much as the average OECD country — yet has the lowest life expectancy and highest suicide rates among the 11 nations.
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The U.S. has the highest chronic-disease burden and an obesity rate that is two times higher than the OECD average.
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Americans had fewer physician visits than peers in most countries, which may be related to a low supply of physicians in the U.S.
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Americans use some expensive technologies, such as MRIs, and specialized procedures, such as hip replacements, more often than our global peers.
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Compared to peer nations, the U.S. has among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.
William Brangham, a reporter for the PBS News Hour (shown in interview, below), delved into comparative reporting on the U.S. health care system and its counterparts in Switzerland, Britain, and Australia. His series is revelatory and worth reviewing, including this “50,000-foot view” of his findings (as told to host Judy Woodruff) after his extensive reporting, much of it conducted before the pandemic:
“[We] went to three countries that provide good, inexpensive, universal health care to their people. And there’s been this debate happening in this country about, ‘Is health care actually a right?’ These are nations that are not having that debate. They’re just doing it for their citizens. And the key metrics that we looked at here are access, quality, cost, and how they take care of the disadvantaged in their societies. And the U.S., frankly, doesn’t do that well on a lot of those metrics.”
Brangham visited Houston, Texas, to see how — in a constrained geographic area — Americans could experience poor health care, with inequities driven by economics and race. They also could get world-class care at nearby institutions pushing frontiers to improve medicine.
In Switzerland, he found how political and philosophical differences can be bridged, especially so private enterprise can continue to play a central role in a nation’s health system. In Britain, he saw how the state can run a universal health care system, with its upsides and downsides. And in Australia, Brangham examined how a hybrid system can thrive by combining a big role for government with private enterprise layered on.
Both the web sites of the Commonwealth Fund and the Peter G. Peterson-Kaiser Family Foundation (KFF) offer users detailed information on how the U.S. rates in multiple health care categories against other nations. Doctors, nurses, health workers, hospitals, and medical researchers in this country deserve high praise for data showing progress for patients in the battle against cancer and heart disease, for example.
At the same time, the spending differences between us and most of our counterparts is stark (see graphic above). And there is much to be said about an important overall measure: life expectancy.
Before the pandemic, this measure showed a wee upturn. But it likely will dip anew, with telling factors slashing at Americans’ life spans including:
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The opioid abuse and drug overdose crisis. This menace had slowed a little but it appears to be spiking anew during the pandemic, with officials fearing that 2020 could be as lethal as years in which 72,000 Americans died due to abuses of powerful painkillers and overdoses of both prescription and illicit drugs.
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Americans taking their own lives, particularly with a steady toll of “deaths of despair.” Suicide already had become a significant public health issue before the pandemic, and mental health experts fear the current high levels of anxiety and depression — combined with big increases in gun purchases — may only worsen this problem. If you are in crisis or know someone who may be, please call the National Suicide Prevention Lifeline at 800-273-TALK (8255) or text HOME to 741741. Both work 24/7. More resources are available at SpeakingOfSuicide.com/resources.
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Increases in women dying of or suffering injury by conditions that once affected men more, notably substance abuse. Women also must deal with major inequities in their health care in the U.S.
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Disparities in available care as well as in the harshness of lives of people of color versus white Americans. African Americans have suffered greatly in the U.S. health system and, along with Latinos and native people, are taking a disproportionate brunt of the coronavirus deaths and infections.
The pandemic will alter the data points that can be helpful for comparing the American health system with others around the world. Still, it will be hard for the U.S. to gain ground with its big toll of infections and deaths. It also will be difficult to argue on a practical level about how Covid-19 patients fared, particularly as experts estimate that uninsured individuals face bills averaging $73,000 if hospitalized for the coronavirus and news reports mount about their struggles with insurers and medical providers about the costs of their care.
Here, too, is what Dr. Ashish Jha, the newly appointed dean of Brown University’s School of Public Health, told Brangham of PBS about the coronavirus and the U.S. versus other nations:
“[T]here are obviously a lot of strengths of our health care system, fabulous doctors and nurses, really good hospitals. But some of the payment issues, I think, have really hindered us. There are examples, like, in nursing homes, when we wanted to start testing health care workers, we couldn’t figure out who was going to pay for it. The bigger issue, in my mind, has been, even though the policy response has been, we will pay for Covid care, the truth is, Americans, especially with high-deductible health plans, or people who don’t have insurance, are deeply worried about costs, and rightly so. And that has really prevented them from seeking care. And, you know, that kind of fear in the middle of a pandemic really makes it hard for people to do what is necessary.
“And so I think, as we emerge from this pandemic, we’re going to really have to look at our payment system and ask: Do we really want people to act like consumers in the middle of a pandemic? Do we really need people to feel that extra set of stress, or can we find a better way?”
Doctors and hospitals have led the way with public warnings about how the pandemic put the U.S. health care system in dire straits — and taxpayers have shoveled billions of dollars in assistance to health workers and institutions. But watchdogs have revealed, too, that this rescue money may have made the already rich in health care even better off, while not necessarily leading to improved medical services for us all. The startling takeaway question may be: Just how grim is the state of Americans’ health care?
With pandemic and partisan politics raging, health needs are a great unifer
A week after Election Day, the justices of the U.S. Supreme Court are scheduled to gather by video conference and to hear arguments in Texas v. California, yet another legal challenge to Obamacare.
Most Americans will not care much about the specifics of the legal issues the high court will be asked to decide. But roughly 20 million Americans will be wondering if they will lose the health insurance they obtained under the ACA. More than 50 million Americans will face uncertainty as to whether their insurers — including those providing policies through their jobs — may return to a time when they could deny coverage based on their pre-existing conditions, which, yes, may include having Covid-19.
U.S. health insurers, depending on the Supreme Court rules, could re-impose annual and lifetime limits on coverage. They could eliminate provisions that allow parents to keep their children on their policies until age 26.
It is unwise to predict how the justices will rule.
But Americans should be crystal clear that Republicans — in the White House, Congress, and statehouses across the country — have pushed the latest federal case that seeks to strike down all of Obamacare.
Further, the GOP has never put forward its own health care plan as an alternative to the ACA, though Trump has promised repeatedly to do so. He staged an event in the midst of his reelection campaign to present a grab-bag of health care statements, which got media fact-checked and were found to have many gaps.
So, whither — or wither — health care in the next presidential term?
Americans, for almost a year, got to hear Democratic health proposals, including far-reaching, single-payer plans (aka Medicare for All) from presidential candidates Bernie Sanders and Elizabeth Warren. Joe Biden, the party’s eventual winner and now its nominee, had different views on health care. You can click here to dive into Biden’s health care positions.
Trump has posted health care materials here, taking advantage of his status as an incumbent.
Voters also may wish to inform themselves by checking out independent, nonpartisan analyses of the two candidates’ health care positions, such as this one from KFF. The organization’s leader also has written for the online Journal of the American Medical Association, comparing the two candidates. They also may find it useful to consult media analyses, including news articles here and here and here and here.
Readers of this newsletter may want to check out our archives. I’ve written for the firm about many current health care concerns. My blog also keeps timely track of medical, scientific, and health issues, with a particular focus on patient safety.
The promise of the internet, as always, is that it provides fast, easy, and abundant material on topical matters, notably medical concerns, diet, nutrition, health policy, and politics. The peril of this firehose of information is that it lacks context and too often accuracy. With crucial decisions looming on the fate of the nation and the health and well-being of ourselves and our loved ones, we need to make time to research with rigor and to weigh with care all claims and promises politicians are making in this campaign season. (Hint: Repeating a falsehood with volume and zeal does not make it true.)
So much of the public focus for the last decade and more, as mentioned, has centered on health insurance. It is a critical part — but not the only aspect —that we need to zero in on when thinking about health care. It may be that the pandemic, and the ferocious discussions about health insurance, are leading people to important fundamentals. These may sound like cliches, but they matter greatly as the nation tries to determine how not just to return to normality but also to a better place, particularly with health care.
Simply put, when it comes to our health as a nation, we’re all in this — together. Your health and well-being matters to me, and vice versa.
We’re all just a blink away from catastrophic injury or illness. Health insurance, in its best form, helps individuals share and balance risk. We all contribute to a shared fund that ensures that our sudden need for medical services won’t be bankrupting. Insurers could be better middle parties, not just holding the risk funds, but also ensuring that payers, providers, and patients recognize and deal with the needs and interests of each other, resolving those equitably. No one begrudges participants in the health care system for earning a fair profit. But who protects patients from getting gouged? Republicans may recoil at the mere mention of government activity in health care. But the rising popularity and efficiency of programs like Medicare and Medicaid suggest that, well, leaving the health care field to private enterprise alone isn’t working so well for all concerned, right?
The pandemic is providing huge lessons, in technicolor, about just how reliant Americans are on their neighbors and their health and well-being. We are obsessed in this time of the coronavirus with knowing that anyone who gets close to us is infection-free. Or that they at least are taking as many protective steps as we are, maintaining distance, washing their hands, and covering their faces. We not only long for the day when our communities achieve “herd immunity” — when enough of us have had an infection or a vaccination so Covid-19 loses its peril for lack of targets — we also have fixated as never before on who among us may be “essential.”
Most of us now value to the moon doctors, nurses, and health workers for their courageous front-line battles with the coronavirus. But at a time of gaping economic inequity, who could have imagined how much wealthy and privileged Americans also could (rightfully) celebrate housekeepers, grocery clerks, delivery people, farm field hands, and many others who earn little and toil without appreciation? Grownups these days have newfound respect for teachers and others who can both care for and educate youngsters — and deal with them during the day, so moms and dads can get their work done.
Powerful social movements, sadly arising out of excessive uses of police force and other injustices, have Americans clamoring not only for legal and political reform but also for improvements in long-ignored inequities in the way medicine treats African Americans — as patients as well as medical professionals. The nation is reckoning with the reality that subpar treatment for some ends up harming us all.
Reciprocal altruism can be beneficial, I long have maintained. It could be a powerful impetus for us to vote, and to consider how our leaders will help us shore up our wobbly health care system and put it on a much-improved, post-pandemic track.
Here’s hoping that you and yours stay healthy and well throughout 2020 and beyond, so you, too, can join in the work for the nation to see a better tomorrow!
Now, about that October vaccine ‘bombshell’ ….
Have political partisans hoisted with their own petards? Have they meddled in such blatant fashion in national health policy that their hoped-for election bombshell has fizzled as an October surprise?
Operation Warp Speed sought to develop a safe, effective, and affordable coronavirus vaccine in record time. In just a few months, with novel approaches rooted in innovative science, the crush for a Covid-19 vaccine — or several of them — has pushed several prospects into the crucial Phase 3 of clinical trials with unprecedented speed.
This is the make-it-or-break-it time for vaccine candidates. They are undergoing rigorous, “blinded” testing in tens of thousands of volunteer subjects, some of whom will get the prospective vaccine while others receive a placebo. They will be carefully monitored over a specified time to see not only if their bodies develop protective antibodies but also if they are safeguarded from coronavirus infection.
Although public health officials, medical scientists, and even Big Pharma vaccine makers have pledged that the painstaking process to test potential coronavirus vaccines would not be rushed, President Trump and his men have insisted without evidence that inoculations would be approved before Election Day, maybe in late October. The political partisans have claimed a vaccine would be in wide use by year’s end. They wanted just enough clinical to authorize emergency use of a vaccine, trumpeting its development as rare good news in the shambolic federal pandemic response.
Medical experts have disagreed. Emphatically.
That has created a rift within the Trump Administration, and between the White House and leading experts on vaccines and infectious diseases.
The federal Food and Drug Administration, as well the Centers for Disease Control and Prevention, have found themselves targets of presidential scorn for countering cheery White House claims about the vaccine timetable as they push plans for tougher product testing.
Angry Trump has accused his own officials of political meddling and demanded they justify their conduct.
But as the dispute has grown, it has undercut partisans’ best-case plans for political benefit from swift development of a coronavirus vaccine. Americans, instead, regard a fast, emergency approval for a vaccine to be worrisome (it’s political meddling they see). They fear that haste may make waste, and negative sentiment has only grown about a coronavirus vaccine.
This is not good news, because officials already had expressed major concern about hesitancy and outright resistance to not only the coronavirus inoculation but also vaccines, in general. If more Americans decline to get a coronavirus shot, its effectiveness, notably in creating “herd immunity,” could be delayed and reduced.
It also is worth remembering that there never has been a guarantee that Operation Warp Speed would result in a safe, effective, and affordable coronavirus vaccine. Experts say that if a vaccine proves out, Americans may not see it in full use until sometime next year, meaning, if it works as hoped, the pandemic may not be in control until the latter part of 2021, at best.
Medical debt really is sickening
Here’s another big problem for the U.S. health care system: For patients in it, getting well can make them sick or sicker.
Consumer Reports, in its timely investigation of the disgrace of U.S. medical debt, found that owing even small sums for health care can cause a cascade of other problems that drag patients down:
“[M]edical debt can harm not only your financial health but also your physical health. One way is by causing you to delay needed medical care. In CR’s survey, 41% of people said they put off a doctor’s visit because of cost. But research shows that the emotional toll of medical bills can also harm health by triggering chronic stress, which is linked to a host of health problems and even premature death.”
CR reported that across American society, patients can be staggered by medical bills. They can get caught off guard by “surprise” charges when providers are not part of their insurance network. Or they may not realize how high their deductibles run, meaning money flies out of their pockets before their coverage kicks in. USA Today, separately, reported that emergency medical transport — aka ambulance services — persists as a way to drive patients to financial ruin with whopping, uninsured charges.
Black and Latino patients, Consumer Reports found, bear disproportionate burdens. In the existing system, the rich get richer and the poor get the shaft.
Still, as the report from one of the nation’s best-known consumer advocacy group found:
“Regardless of race, medical debt is emotionally draining … research has linked high-debt stress to ulcers, digestive problems, and impaired sleep. But chronic stress over money might affect health in less obvious, even more serious ways. The connection is so concerning that two regional Federal Reserve banks—in San Francisco and Atlanta—have looked at how medical debt impacts the health of U.S. citizens. The San Francisco review, citing previously published medical research, noted that adrenaline and cortisol released by the body in response to chronic stress linked to finances can elevate blood pressure and heart rate, and impair memory and immune function.
“In an even more robust 2016 analysis, the Atlanta study used credit histories to link high debt loads and debt delinquency with mortality. In other words, the bigger a person’s unpaid debt, the higher their risk of dying early. Further, they found that a 100-point improvement in a person’s credit score is associated with a 4% decline in their risk of death.”
Besides delayed care, the ever-increasing costs of medical services can force families with crushing decisions about complex prescription drugs and therapies. These can bankrupt them but promise to improve their health outcomes, even for a while, with difficult diseases like cancer. Specialists have only begun to deal with this core challenge in their care, diagnosing it as “financial toxicity.”
Specialized care also simply can be unaffordable and inaccessible to the poor and sick, leading to deadly delays in treatment and needless worsening in patients’ already poor condition.
The Consumer Reports article includes helpful suggestions about dealing with medical bills, a topic I’ve also addressed. It may be a maddening and exhausting chore when patients are ill and least need more worries heaped on them. But don’t stick your head in the sand about those awful medical expenses. Dig in. Ask questions. Challenge every line item. Don’t hide. Negotiate aggressively. Get help in doing so if you can.
Recent Blog Posts
Here are some recent posts on our patient safety blog that might interest you.
- A personal story about a client of ours who was able to push for better safety practices in blood banking at the National Institutes of Health, so that what happened to his loved one won’t happen to anybody else.
- A gripping story from Detroit about the patients of a malpracticing cancer doctor who were able to forgive him as he was sentenced to prison.
There’s a new scorecard for surgeons’ complication rates. But is it ready for prime time?
Sincerely,
Patrick Malone
Patrick Malone & Associates
